Two years is not enough: Learning from the past, looking to the future

Kendall Noel

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Two years should be more than enough...
Ahmed Mian

Published on: 22 May 2010
Two years could be enough--if the world of community practice was more supportive...
J. Galt Wilson

Published on: 18 May 2010

Published on: (22 May 2010)
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Two years should be more than enough...
Ahmed Mian, Family Medicine Resident
I read Dr. Kendall’s commentary on lengthening family medicine residency training with great interest. Disappointingly, his ultimate suggestion was not an innovative solution, especially since there was no clear or valid training objectives articulated for that year i.e. spending time in colonoscopy or colposcopy clinics hardly warrants an extra year of training. Additionally, good residency programs already utilize thei...
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I read Dr. Kendall’s commentary on lengthening family medicine residency training with great interest. Disappointingly, his ultimate suggestion was not an innovative solution, especially since there was no clear or valid training objectives articulated for that year i.e. spending time in colonoscopy or colposcopy clinics hardly warrants an extra year of training. Additionally, good residency programs already utilize their residents to run clinics and supervise junior housestaff during their second year of training. A third year is not needed for that.
Blaming current contract conditions, information overload of the modern era, and desiring to emulate the United States training method are all fallacies. The idea of ‘lets add an extra year’ is more reactionary than visionary. At this rate, every few years, all we will be doing is adding more years for training. Those responsible for delivering resident training should instead undertake a sincere and critical self-analysis on how to utilize the two years most effectively to provide optimal training. If indeed residents either do not feel prepared to enter practice by the time they are done or are increasingly pursuing enhanced skill years to further their education, the question should be, why are these programs failing to deliver their training mandates? Maybe the college needs to revisit what rotations are mandatory in family medicine. For example, the reality of today is that the vast majority of residents do not practice obstetrics, yet we still have two months of it stipulated. Instead that time could be more appropriately allocated to palliative care or elective time.
This approach to thinking is especially poignant at a time when those that are truly at the forefront of medical education are realizing that length of training does not necessarily translate into the development of a quality requisite skill set. Instead, these leaders are advocating moving away from a time based to competency based training system, where specific skills are taught and assessed.
Dr. Kendalls’ statement that ‘it would really only be one year’ reflects a disregard towards the reality of today’s competitive medical student landscape. The majority of medical students actually have more than an honours degree. Most possess either a masters, PhD, or another professional degree and consequently are in their mid to late twenties before they even start medical school. By the time they are done, with today’s astronomical tuition fees, they are graduating with average debt loads of $150,000. Some are even in relationships with children by the time they start residency. They can not even moonlight as in the old days, when one year of a rotating internship was also enough to grant you a general license. The financial deterrent does not end there, as lengthening the training time will definitely detract even more people from coming into family medicine, when the reality is spending another year (as in general internal medicine) or two (sub-specialties) would result on average of a near doubling of annual salary. This is not to mention the significant health human resource implications of delaying the entry of trained residents into practice by adding a year to a system that may not even have the capacity to accommodate them. Furthermore, the more time spent in training, the more likely trainees will want to stay in academic medicine, urban centres, or develop an even more concentrated niche of practice, thereby even further reducing recruitment of physicians into community settings currently in desperate demand for their skill set.
This reactionary idea will lead to a number of detrimental effects with no overwhelming convincing need. It is important that those in positions of influence patiently look to more innovative and collaborative ideas. Most vitally, they must work in close consultation with residents in family medicine and representative organizations who would be in the best position to relay their real experiences, since being engrossed in the process, they are the ones more in tune with deficiencies in contemporary training and how best to rectify them. Especially because they are the ones that stand to be the most affected by any changes.
Yours Sincerely,
Ahmed Mian Hon.B.Sc., B.Ed., M.D. University of Toronto PGY1 Family Medicine
Chief Resident The Credit Valley Hospital, PAIRO Board of Directors, CAIR Representative to the CFPC Accreditation Committee
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Competing Interests: None declared.
Published on: (18 May 2010)
Page navigation anchor for Two years could be enough--if the world of community practice was more supportive...
Two years could be enough--if the world of community practice was more supportive...
J. Galt Wilson, FP/College Deputy Registrar
I very much enjoyed Dr. Noel's thoughtful, balanced commentary that ultimately advocates for a three year residency program.
He does a very good job of canvassing the contrary position. I found his "Parkinson's law" concern compelling--the risk that "...the same material covered in a 2 year curriculum" might simply be spread over a longer period. The capacity challenges posed by any attempt to extend the dura...
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I very much enjoyed Dr. Noel's thoughtful, balanced commentary that ultimately advocates for a three year residency program.
He does a very good job of canvassing the contrary position. I found his "Parkinson's law" concern compelling--the risk that "...the same material covered in a 2 year curriculum" might simply be spread over a longer period. The capacity challenges posed by any attempt to extend the duration of the program during this period of massive expansion of undergraduate enrollment make this inevitable in my view. As things currently stand, second year residents (in BC at least) are increasingly challenged to secure meaningful electives, such is the competition from the growing ranks of clinical clerks and specialty residents.
Then there are the twin pragmatic obstacles--governments have no money at present and, even allowing for the fact that "...it would only be for one year", a graduate hiatus in the current climate of perceived provider shortages is politically intolerable. Asking provinces to endorse a third year in this context is asking the impossible.
So, for the near term at least, a three year program seems unlikely.
Fortunately, there is a workable alternative--even more aggressive promotion of group practice models. Even with the significant improvements brought on by primary care reform initiatives, the work environment in our discipline (and most of the others) remains incompatible with the life aspirations of large numbers of new graduates-- particularly young women with children. Recruitment to practices increasingly depends on accommodating young people. Business management responsibilities must be covered off and specified hours of work guaranteed. More creatively, mentoring by more experienced colleagues needs to be part of the package.
Dr. Noel appropriately concludes with a reference to "lessons of the past". The slightly more distant past also holds some useful examples of what can be done to bring along inexperienced, younger colleagues. Many of our most respected older family medicine teachers came of age when postgraduate training included little or no formal curriculum--usually a rotating internship, followed by, for example, six months each of anaesthesia and obstetrics. In clinical education parlance, "...all service and no teaching". Those doctors made the transition to "master clinician" competencies by joining supportive medical communities, often, but not always, based in clinic groups or small town hospitals. Every working day began with an opportunity, over coffee in the medical staff lounge, to discuss cases with more experienced colleagues.
No one is advocating reverting back to laissez faire learning. But it's a sad reality of the past two decades that family medicine has tended to become more fragmented, despite explicit efforts to model team-based service provision in training. Communities of family physicians are working hard in many places to address that. The fruits of their efforts have the potential to recreate the on-the-job learning opportunities of the past, without the inhumane hours and expectations that are simply no longer acceptable.
While it is obviously true that two year trainees are not "master clinicians", I question whether a third training year is the best way to solve that. Early practice experience in well-functioning groups has the potential to consolidate and build on foundation clinical skills, while, not incidentally, being paid as a real doctor.
Galt Wilson, MD MSc FCFP.
PS I do acknowledge the "hunger" for third-year programs Dr. Noel cites. It's not new. My other concern is the extent to which so many of them lead new graduates away from generalist practice at a time in their professional lives when they need it as a key component of their professional formation and confidence. I'd suggest mandating a minimum five years of community general practice as a prerequisite for primary care subspecialty training (sports medicine, emergency medicine, palliative care, geriatrics, addictions, GP oncology, and so on)--but that's another matter entirely and possibly just me!
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Competing Interests: None declared.